In the 1950’s George Papanicolaou and Herbert Traut
developed a test to screen for cervical cancer in women called the pap
smear test. This was at a time when cervical cancer was the leading
cause of death in women in the United States. Currently, cervical cancer
ranks 13
th on the list of causes of death in women in the
U.S. Thanks to the pap smear test precancerous lesions, called
dysplasia, are diagnosed more frequently than invasive cervical cancer.
Annual screening and early diagnosis give physicians a chance to start
treatment and
prevent cervical cancer. Some risk factors for cervical cancer include
1:
-
Multiple sexual partners
-
Young age at first intercourse (<16)
-
Having intercourse with uncircumcised partner
-
Unprotected intercourse
-
Human papillomavirus
-
Chlamydia and HIV
-
Immunocompromised
-
Smoking
-
Poor nutritional status
-
Diethylstilbestrol (DES) exposure
-
Long term oral contraceptive use (>5 years)
-
Low socioeconomic status
-
Lack of access to health care or health insurance
-
Rural residence
The main risk factor for cervical cancer is the presence of human
papillomavirus (HPV) infection. It is estimated that cervical infection
with one of 15 HPV types account for all cervical cancers.
2
HPV type 16 is the most common carcinogenic HPV type detected in women
with cervical cell changes including precancerous lesions and cancerous
lesions. Other HPV types implicated in cervical cancer include;
18,31,33,35,39,45,51,52,56,58,59,66,68,73,and 82.
2
"...an alternative approach to
managing...pap results & cervical epithelial neoplasia...begins by
educating the patient on safe sex practicing to decrease transmission of
HPV, HIV and other sexually transmitted diseases..."
It is important to screen women for high risk HPV along with their
annual pap smear which screens for cervical cell abnormalities.
HPV testing
can be performed during the pap smear. Most pap smear cytology is now
done with liquid based cytology using the Thin Prep or SurePath vial
which has the ability to test for both cervical cytology and HPV. A
separate swab test for HPV also exists and is called the Digene probe.
We now can identify the exact high risk strain a woman has by running an
additional test for HPV genotype.
Screening
Recently the American College of Obstetricians and Gynecologists, ACOG,
made the following changes in regards to screening guidelines for how
often a woman should get a PAP smear.
3 The new guidelines recommend less frequent screening for certain age groups.
-
Women ages 21 to 30 will be screened every two to three years instead of every year.
-
Women age 30 and older who have had three consecutive negative
cervical cytology test resultsand who have no history of moderate
cervical dysplasia (CIN 2) or severe cervical dysplasia (CIN 3), are not
HIV infected, are not immunocompromised, and were not exposed to DES in
utero may be screened once every three to five years.
-
Women of any age with certain risk factors may need more frequent
screening, including those who have HIV, are immunosuppressed, were
exposed to diethylstilbestrol (DES) in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.
-
Women over the age of 30 should have both cervical cytology test and
high risk HPV testing. This is referred to as combination test.
-
Women under 30 should be tested for high risk HPV if the pap comes
back as atypical cells of undetermined significance, or ASCUS. This is
called reflux testing and can be done from the same sample if liquid
based cytology is done.
-
It is acceptable to discontinue cervical cancer screening between 65
years and 70 years of age in women who have three or more negative
cytology test results in a row and no abnormal test results in the past
10 years.
In the past ACOG recommended that cervical screening begin three years
after first sexual intercourse or by age 21, whichever occurred first.
Moving the baseline cervical screening to age 21 avoids unnecessary
treatment. Although HPV infection is high among sexually active
adolescents, invasive cervical cancer is rare. The immune system clears
the HPV infection within one to two years among most adolescents. The
large majority of cervical dysplasia in adolescents resolves on its own
without treatment.
Treatment
Conventional management for cervical dysplasia includes colposcopy with
endocervical sampling to determine the extent and degree of dysplasia
which is categorized as cervical intraepithelial neoplasia, CIN, and
graded level I, II, or III.
4
The American Society for Coloposcopy and Cervical Pathology, ASCCP, has
determined guidelines for conventional management of cervical
intraepithelial neoplasia. They include;
5
-
CIN I and satisfactory colposcopy- Follow-up without treatment with
PAP and HPV test at 6 months. This is called ‘watch and wait.’ If still
positive repeat the colposcopy. Alternative approach is to follow-up at
12 months with repeat colposcopy. A third approach is to treat
immediately with cryotherapy or a loop electrosurgical excision
procedure,LEEP.
-
CIN I and unsatisfactory coloscopy- diagnostic excisional procedure (cone biopsy)
-
CIN II and III with satisfactory colposcopy- LEEP or diagnostic excisional procedure
-
CIN II and II with unsatisfactory colpo- diagnostic excisional procedure (cone biopsy)
The goal is to remove the abnormal cells and shed the top layer that
holds the virus. But, the virus is in the body and conventional
treatmentsdon’t treat the whole body, support the immune system, or
systemically treat HPV. Also, there are complications from cryotherapy
and LEEP that will make pregnancy and child birth more difficult.
There are options
Naturopathic physicians offer an alternative approach to managing both
abnormal pap results and cervical epithelial neoplasia. Addressing the
cause is key to treating the disease. This begins by educating the
patient on safe sex practicing to decrease transmission of HPV, HIV and
other sexually transmitted diseases. Smoking is linked to cervical
cancer as it increases the duration of infection with high risk HPV.
6
Smoking also weakens the immune system. Smoking cessation and
supporting the immune system are an important part of treatment for
cervical dysplasia. Poor nutritional status is linked to cervical
cancer. Folate and B12 deficiency has been associated with increased HPV
infection.
7 Low serum retinol levels has been linked to increased risk of cervical epithelial neoplasia.
8 A comprehensive nutritional intake and dietary counseling should be included in treatment.
No need to watch and wait
When the pap comes back with ASC-US and no HPV, normal cytology with HPV
present, or ASC-US with HPV in the younger women, conventional medicine
suggests to watch wait and repeat the pap. This is where naturopathic
medicine would begin treatment. Supporting the immune system to fight
off HPV as well as treating HPV directly can reverse the low grade
cervical cell abnormality and eliminate HPV. Guidelines for referral to
colposcopy are the same.
Naturopathic medicine can also treat cervical intraepithelial neoplasia I
and II. This treatment consists of oral systemic support as well as
local vaginal treatment of the cervix. Some important herbal medicines
and nutrients to consider include:
Folic acid
There have been several studies showing low serum folate levels are
linked to cervical dysplasia and high folate blood levels are linked to
the prevention of CIN I.
9,10 Improvement in cervical dysplasia using
folic acid supplementation is also well documented.
11 The doses vary and are most often given with vitamin B12 as not mask B12 anemia.
Indole-3-carbinol
Indole-3-carbinol (I3C) is present in all members of the cruciferous
vegetable family including cabbage, broccoli, Brussels sprouts,
cauliflower, and kale. Studies indicate I3C has the potential to prevent
and even treat a number of common cancers, especially those that are
estrogen related.
12
In a double-blind, placebo controlled study, 30 patients with
biopsy-confirmed CIN II-III were randomized to receive placebo or 200 or
400 mg oral I3C daily for 12 weeks. Three patients did not complete the
study. None of the 10 patients in the placebo group had complete
regression of CIN. Four of eight patients in the 200-mg/day group and
four of nine in the 400-mg/day group had complete regression of CIN.
13
I3C is easily available over the counter as a supplement or simply by
eating 4-5 servings of the cruciferous family vegetables a day.
Antioxidants
Antioxidants are known for their cancer prevention properties. Studies
have linked antioxidant levels to CIN and cervical cancer. In one study,
blood levels of coenzyme Q10 (CoQ10) and vitamin E were measured in
patients with biopsy-confirmed CIN, cervical cancer, and in controls
with normal PAP smears. Results showed levels of CoQ10 and Vitamin E
were significantly lower in patients with diagnosed CIN and cervical
cancer when compared to controls.
14 Levels of
CoQ10 from cervicovaginal epithelial cells were measurable and also appeared to be significantly lower in women diagnosed with CIN.
15 These findings suggest low levels of these two antioxidants may play a role in the pathogenesis of cervical dysplasia.
Vitamin C
Vitamin C is an excellent antioxidant that boosts the immune system and
has proven anti-cancer effects. It is known that women with cervical
dysplasia have low blood levels of vitamin C.
16 A recent studied showed that women with high intake of dietary vitamin C had a reduction in the risk of cervical dysplasia.
17
A study on Korean women looked at 58 colposcopy confirmed cases of CIN
and compared them to 86 women with normal pap smears. The plasma
concentration of Vitamin C was significantly lower in the CIN group than
in the control group.
18 This suggests a role for Vitamin C in the treatment of cervical dysplasia.
Green tea extract
Epigallocatechin-3-gallate (EGCG) is the standardized extract from green
tea. It is known to inhibit epidermal growth factor receptor which is
needed for cervical cell growth. A recent study looked at 51 women with
HPV infected cervical lesions divided into 4 groups and compared them to
39 controls. Green tea ointment was applied locally to 27 patients
twice a week. For oral delivery, a EGCG capsule was taken orally every
day for eight to 12 weeks. In the study, 20 out of 27 patients under
ointment therapy showed a response. Six out of eight patients under
green tea ointment plus capsule therapy showed a response. Six out of 10
patients under EGCG capsule therapy showed a response. Overall, a 69%
response rate was noted for treatment with green tea extracts, as
compared with a 10% response rate in untreated controls. A good response
meant an improvement in cervical dysplasia.
19
Coriolus versicolor
Coriolus is a mushroom commonly used in Asian cultures for its immune
properties. It is often called an immunomodulator and has been studied
for it is immune enhancing properties in cancer patients undergoing
chemotherapy. Recently is has been studied for its immune modulating
effects on HPV and reversing early stages of cervical cancer.
20
A study published in the Townsend Letter November 2006 by J. Silva
Couto looked at women with cervical dysplasia, LSIL (CIN I and HPV).
Half of the women in the LSIL group were given 3g/d Coriolus a day for
one year and the other half took none. Dr. Silva Couto found that
Coriolus versicolor supplementation over a period of one year
substantially increased regression of the dysplasia (LSIL) and induced
clearance of the high risk sub-types of the HPV virus. Some interesting
findings of the study include;
a) Coriolus versicolor supplementation demonstrated a 72% regression
rate in LSIL lesions compared to 47.5% without supplementation.
b) Coriolus versicolor supplementation demonstrated a 90% regression
rate in the high risk HPV virus sub-types compared to 8.5% without
supplementation.
Local treatment applied to the cervix
Escharotic treatment
The use of escharotic or caustic treatments for epithelial cancers is
based on a centuries-old observation that select plant and mineral
extracts could be used to treat topical skin lesions. Two small studies
show the efficacy of this treatment in reversing cervical dysplasia in
women.
21,22
This treatment is used for CIN I and II after a satisfactory colposcopy
is performed and if there is no disease in the endocervical canal and
no glandular cells present. Escharotic treatment for cervical dysplasia
involves the local application of a natural enzyme, bromelain, to the
surface of the cervix. This is left in place for 15 minutes with heat
applied to activate the enzyme. The proteolytic properties in bromelain
dissolve the top layer of cells on the cervix which are infected and
damaged by the HPV virus. A mixture of zinc chloride and a plant
Sanguinaria is applied to the cervix to cause sloughing of abnormal
tissue. Zinc chloride is caustic and acts to disrupt the cellular
membrane integrity and the mucus over coating to allow the Sangunaria to
penetrate the cells. Sanguinaria has been shown to have anti-neoplastic
qualities.
21
The treatment is performed twice per week with at least two days in
between treatments for 4-5 weeks. The ZnCl solution is made by a
compounding pharmacist.
Vaginal suppository treatment
Vaginal depletion packs have been in use since the 1800s. Vaginal
depletion packs, Vag pak, work by the action of the substances within
the packs, which draw infection out of the cervical cells and boast the
immune system. Each suppository contains: magnesium sulfate, glycerin
complex, hydrastis tincture, thuja oil, tea tree oil, bitter orange oil,
vitamin-A (as palmitate) 100,000 iu, ferric sulfate,ferrous sulfate in
polybase. Hydrastis canadensis is effective against many microbial
pathogens, as are the essential oils of tea tree, thuja and bitter
orange.Vag Pak suppositories are often used for mild dysplsia and/or
high risk HPV.
Green tea suppositories made from a pharmacy are also effective for
cervical dysplasia and HPV. ECGC in green tea was evaluated on cervical
epithelial; cells and cervical cancer cells and HPV. Green tea inhibited
cancer cell growth, induced apoptosis, decreased gene expression, and
cell cycle changes.
23 As mentioned earlier green tea has been shown to be effective against HPV.
Critics of natural medicine say there is no published evidence that
these options work or are backed in science. There are several recent
published articles explaining the science and patient outcomes. One can
be found at
http://www.ncbi.nlm.nih.gov/pubmed/19679625
Summary
It is important that a woman is informed of her options for managing
cervical health. The least invasive, most natural, safe and effective
treatments that address the cause should be offered. There are times
natural medicine is not an option for treating cervical cell changes due
to the severity and location of disease but in many cases naturopathic
treatment of cervical dysplasia and HPV is the safest and most effective
option.
References
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Medscape OB/GYN & Women’s Health. 2003;8(1):1-12
2. Wheeler C. Advances in primary and secondary
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vaccines and testing.
Nat Clin Pract Oncol. 2007;4(4):224-235.
3. ACOG.org
4. Wright TC, et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests.
Am J OB/GYN 2007;11:346-355.
5. Wright TC, et al. 2006 consensus guidelines for
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adenocarcinoma-in-situ.
Am J OB/GYN 2007;11:340-345.
6. Synder U. A look at cervical cancer.
Medscape OB/GYN & Women’s Health. 2003;8(1):1-12
7. Weinstein SJ, et al. Low serum and red blood cell
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risk of invasive cervical cancer.
J Nutr. 2001;131:2040-2048.
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Cancer Epidemiol Biomarkers Prev. 2001;10:1219-1222.
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